Provider Demographics
NPI:1508525585
Name:MADDEN, MICAH (NP)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:MADDEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 BARRIX DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-3305
Mailing Address - Country:US
Mailing Address - Phone:304-687-8215
Mailing Address - Fax:
Practice Address - Street 1:10455 N CENTRAL EXPY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-2213
Practice Address - Country:US
Practice Address - Phone:972-704-1091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1034186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily